Clinical Practice Guideline

for

PROSTATITIS

Developed for the

Aerospace Medical Association

by their constituent organization

American Society of Aerospace Medicine Specialists

 

Overview: Prostatitis is the most common urologic diagnosis in men younger than 50 years of age and is the 3rd most common diagnosis in men greater than 50 years of age. It is defined as an increased number of inflammatory cells in the prostatic parenchyma. The National Institute’s of Health (NIH) classification for prostatitis is recognized as the best clinical classification system.   

      1.  Acute bacterial prostatitis (NIH category I) – This category is relatively uncommon. Findings may include fever, genitourinary pain, obstructive voiding symptoms, dysuria, urgency and frequency. Patients may also present with malaise, nausea, vomiting and can progress to frank septicemia. The most common organisms are gram negative enterobacteriaceae such as E. coli from gastrointestinal sources and less commonly gram positive enterococci. Initial diagnosis is made by history, physical, urinalysis and culture. A digital rectal exam may be performed with gentle prostatic palpation but prostatic massage is NOT performed as it can lead to bacteremia. The PSA may be acutely elevated but will subside over the ensuing weeks and should be followed toward normal particularly in the older population. Midstream urine will show significant WBCs and may show bacteruria with a positive culture. In a military field setting, the lab may be a simple dip stick type urinalysis with no culture available. Treatment for uncomplicated cases requires 2 – 4 weeks of oral antibiotics. For those significantly ill or who fail to respond to oral treatment rapidly, consider an abscess and treat with intravenous antibiotics and urologic referral.  Consult a current pocket antibiotic reference book for the most appropriate agent based on patient age, potential pathogens and resistance patterns as recommendations change with time.

      2.  Chronic bacterial prostatitis (NIH category II) – NIH II typically affects men aged 40 -70 years of age. The patient usually has a history of recurring lower urinary tract infections (UTIs).  The bacteria reside in aggregates or biofilms found in ducts and acini of the prostate gland. The risk for recurrence is greater in those with functional voiding abnormalities or inadequate initial treatment of acute prostatitis. Organisms such as Chlamydia trachomatis may also play a role in some patients.  For diagnosis of NIH category II or higher, examination of urine and urine culture before and after prostatic massage is needed. A digital rectal exam with gentle prostatic massage should be performed after the patient has produced the first urine specimen followed by a post-massage urine sample. The massage is not done on a patient with a significant acute illness to prevent inducing a bacteremia. The post-massage urine sample has increased WBCs and may reveal pathogens but cultures may be sterile unless an acute UTI is also present.  Antibiotic treatment may range from 1 – 3 months depending on the medication chosen and the severity of illness.  This category requires a urologic evaluation to eliminate a functional abnormality.

      3. Chronic Pelvic Pain Syndrome or CPPS (NIH category III) – This category is composed of two sub-types and accounts for the majority of all prostatitis cases. NIH III type A and B CPPS have persistent chronic genitourinary pain without uropathogenic bacteria. The syndrome becomes chronic after three months of duration and quality of life is significantly affected. Examination of urine and culture before and after prostatic massage is required. Treatment may involve anti-inflammatory treatment and/or alpha-adrenergic blockers to improve urine outflow. Empiric antibiotic therapy may be useful but it is not understood if improvement results from an antimicrobial action on uncultured organisms or from an anti-inflammatory affect.  Urologic consultation is required.  

           Nonbacterial prostatitis or inflammatory CPPS (NIH category IIIA) – Patients may complain of traditional symptoms of prostatitis but report increased pain localized to the perineum, suprapubic area, penis, groin or lower back. Additionally, they may report pain during or after ejaculation. Increased numbers of WBCs are found in expressed prostatic secretions and may also be found in the post-prostatic massage urine or semen. All cultures are negative. Flight surgeons should be aware there may be an association between this syndrome and an increased incidence of depression or psychological disturbances.

           Prostatodynia or noninflammatory CPPS (NIH category IIIB) – The symptoms are similar to IIIA. All cultures are sterile and there are insignificant or no WBCs found in expressed prostatic secretions, post-prostatic massage urine or semen. This syndrome may result from smooth muscle tone abnormalities in the prostatic urethra. 

      4. Asymptomatic inflammatory prostatitis or AIP (NIH category IV) – WBCs are expressed in prostatic secretions, post-prostatic massage urine sediment, semen or histological specimens of the prostate gland but the patient has absolutely NO symptoms. No infection is present, cultures are negative and patients frequently have benign prostatic hypertrophy and/or an elevated PSA. A noninfectious etiology may be present such as prostate cancer. Urologic consult is required.

Aeromedical Concerns:  In general, return to flying status is dependent on the NIH classification, side effects of the antibiotic selected, time to clinical resolution and applicable policy from the designated regulating authority.

 

Environment: Vibration in the cockpit may traumatize the perineal area and aggravate prostatitis so a temporary grounding can assist in recovery. Those assigned to high G-force aircraft may also exacerbate the condition secondary to the G load in the perineal area.  

 

Medication selection:  The more common civilian choices include quinolones (like ciprofloxacin),

doxycycline, macrolides, and Trimethoprim-Sulfamethoxazole (TMX/SMX). The service branches have

individual medication lists vetted for flight approval but these lists are not identical. Quinolones can

shorten the course of treatment but have the increased risk for central nervous system side effects

compared to other antibiotics. Ciprofloxacin and levofloxacin have been waived in some service

branches.  There is no FAA restriction on quinolone use. For acute prostatitis, once an idiosyncratic

medication reaction is ruled out and symptoms have resolved, the airman can return to flying status. This

assumes the medication was chosen from the vetted list for the Air Force, Army, Navy or FAA. Use good

operational risk management for drug selection and reference your antibiotic pocket guide as

recommendations change with time. For aviators requiring prolonged antibiotics in areas with significant

increased sun exposure, be cognizant of the drugs with increased risk for photo dermatitis (like

doxycycline) and adjust treatment or sun exposure warnings accordingly.

 

Consultation: Aviators with NIH category II-III may have reasons for recurring infections such as dysfunctional voiding, intraprostatic ductal reflux, pelvic floor musculature abnormalities, neural dysregulation or prostatic calculi requiring special urologic studies. Consultation is generally required to rule out other pathology. NIH IV has special risks for prostatic cancer and requires consultation.

 

Medical Workup: The workup should include: a thorough history, complete examination, urinalysis, cultures and discussion of all associated symptoms and medication side effects. Labs such as CBC and PSA should be submitted if performed.  If obtained, the urologist’s diagnosis, prognosis, reports and tests results are to be included. For those with CPPS, psychological status should be addressed.

 

Aeromedical Disposition (military): Please refer to service specific guidance as there is some variation. 

NIH I: No waiver required. Treat the aviator with empiric antibiotics for 2-4 weeks (duration based on

antibiotic chosen) or based on cultures if available. Ground the aviator during the acute illness. If an

antibiotic is selected from an approved aircrew list, the aviator can be returned to flying status when

symptoms have resolved and no adverse medication reaction has been demonstrated.

NIH II: A waiver is required. Chronic bacterial prostatitis is often asymptomatic between episodes of

acute exacerbation. For all three services, the risk of recurrent exacerbations with rapid onset of

symptoms require grounding unless the infection is cured or suppressed with antibiotics.  Urologist

consultation is generally required to rule out other voiding abnormalities and a waiver is required for the

condition and continued antibiotic use.

NIH IIIA and IIIB: Nonbacterial prostatitis and prostatodynia will require urologic consultation and waiver

approval for all three services. Psychological factors may also need consideration.

NIH IV: This diagnosis requires urologic evaluation and a waiver for all three services.

 

Aeromedical Disposition (civilian): For antibiotic use, once the idiosyncratic reaction to the drug is ruled out and the symptoms have resolved the airman can return to flying status.  The presence of chronic pain, the use of a disqualifying medication, the finding of cancer or the demonstration of a psychological disorder would require a special issuance.

 

Waiver Experience (military): There are 31 aviators in the USAF electronic waiver file approved for flight with the diagnosis of prostatitis.  Fourteen of these were approved for flight while on antibiotics. 43% of those on antibiotics were approved for ciprofloxacin or levofloxacin, 36% for TMX/SMX and 21% for doxycycline. Three aviators were disqualified. One of 31 was diagnosed with CPPS.

 

Waiver Experience (civilian): Special issuance is not required for this condition.

 

References:

 

Air Force Instruction 48-123V, A4.21.10 Chronic Prostatitis, prostatic hypertrophy with urinary retention or abscess of the prostate; 5 June 2006.

David RD. Rational antibiotic treatment of outpatient genitourinary infections in a changing environment. Am J Med July 2005; 118 (7A): p 7S – 13S.

Dehart RL, Davis JR, et al. Selected Medical and surgical Conditions of Aeromedical Concern, Prostatitis. In: Dehart RL eds. Fundamentals of Aerospace Medicine, 3rd Ed. Philadelphia: Lippincott Williams and Wilkins; 2002: p451.

Federal Aviation Administration. Aviation Medical Examiner (AME) Information. http://www.faa.gov/about/ office_org/ headquarters_offices/avs/offices/aam/; cited 11 Sept 2007.

Hua VN. Acute and chronic prostatitis. The Med Clin N Am. 2004; 88: 483-494.

Kim ED. Bacterial prostatitis. E Medicine. 14 June 2005: p 1-15; http://www.emedicine.com; cited 21 August 2007.

Nickel JC. Chronic bacterial prostatitis: An evolving clinical enigma. Urology. 2005; 66 (1): p 2-8.

Nickel JC. Prostatitis and related conditions. In: Walsh PC eds. Campbell-Walsh Urology, 9th Ed. Philadelphia: Saunders; 2007: 1-31; http://www.mdconsult.com; cited 21 August 2007.

NOMI Aeromedical Waiver Guide. 16.3, Prostatitis. http://www.nomi.med.navy.mil/NAMI/ WaiverGuideTopics/index.htm; cited 21 August 2007.

 

Rayman RB, Hastings JD, Kruyer WB, Levy RA, Pickard JS. Clinical Aviation Medicine. 4th ed. New York: Professional Publishing Group; 2006: 280-281.

US Army Waiver Guide. Prostatitis. https://aamaweb.usaama.rucker.amedd.army.mil/

AAMAWeb/policyltrs/Army_APLs_Mar06_v3.pdf; cited 21 August 2007.

 

2/15/08